An important function performed by healthcare providers (such as hospitals, clinics or physicians) is the sending of claims to healthcare payer institutions to obtain reimbursement for provision of services to a patient. These claims may be in electronic or paper format. Paper claims typically go through a data entry process that converts them to an electronic format. The entered electronic claims are usually sorted, indexed and archived. Each claim is processed in a payer institution adjudication system. The payer adjudication system interprets the claim data and determines whether or not the claim is to be paid in full, partially paid or denied. This adjudication process may be fully automated, partially automated, or manual. The results of claim adjudication may include the issuance of a check and an explanation of benefits (EOB) to the insured and healthcare provider, or a request to send additional information. The process of reviewing claims is labor-intensive and error-prone.
Known adjudication systems help payers and providers streamline their claims payment and medical case management processes. A typical adjudication system employed by a payer institution, may use high speed scanning equipment and optical character recognition software to translate paper claims into electronic data. The electronic claim data is processed by rule based software to interpret the claim data for any conflicts. Healthcare providers do their best to ensure claims are accurate before they send them to the payer by embedding payer rules into their software applications or by utilizing “claim scrubbing” applications to evaluate claim data prior to submission to the payer. Known systems also approach claim data processing from a piecemeal perspective whereby, for example, one software vendor system addresses online eligibility and electronic remittance and a different vendor system addresses revenue management from a physician perspective. Another vendor system supports claim editing, but only after the claim is generated. Further known systems require significant user intervention once a claim is produced.
Known systems fail to approach claims processing and management from a combined payer, provider and patient perspective. Prior solutions approached the problem from a piecemeal perspective and failed to interact dynamically with clinical events and clinical information systems in the healthcare provider environment. Typically one vendor system addresses automated eligibility and a separate vendor system supports electronic payment, for example and an overall result is that there is inefficiency and error introduced through the lack of financial system and clinical system interaction. This results in claims that fail the edit process upon receipt by the payer and consequent disallowance by the payer. Disallowed claims cause delayed payment and negatively impact healthcare provider cash flow and patient satisfaction with the process. A system according to invention principles improves clinical and financial data processing operation interaction and thereby claim accuracy prior to claim submission to a healthcare payer institution.